The National Health Care for
the Homeless Council is pleased to make this Executive Summary available. The
full report is available for $10.00 on our Publications page.
Executive Summary
July 1995
"Homelessness is hazardous
to your health." This understanding shapes Health Care for the Homeless
programs throughout the United States. Homelessness exacerbates existing
health problems, creates new health problems, and serves as a serious barrier
to accessing health care. As Health Care for the Homeless (HCH) providers
bandage wounds, prevent the spread of tuberculosis, or manage the ravages of
HIV disease, they must also labor to assure that the means to meet the basic
needs of shelter, food, and clothing are available. Because low-skill
employment paying livable wages is often not available, and because many
homeless people are for various reasons unable to participate in the labor
market, "welfare" often means the difference between meeting basic human needs
and a miserable existence on the streets. Income support such as Aid to
Families with Dependent Children (AFDC), Supplemental Security Income (SSI),
or General Assistance (GA) may be the only path to stability and dignity.
The Federal Government will
likely adopt significant welfare reform measures in 1995. A number of State
governments have already made important changes to assistance programs for
families and individuals, and in 1996 the focus of welfare reform efforts will
shift to the States. Unfortunately, it is likely that these measures will
exacerbate homelessness:
•Given the punitive nature
of programmatic changes and the sharp decreases in funding for public
welfare programs, it is probable that tens of thousands of Americans will
lose cash benefits and, in short order, their homes.
•The publicly-funded
resources which programs such as Health Care for the Homeless use to bring
housing and stability to those living on the street are rapidly
disappearing, severely limiting the positive impact of efforts to resolve
homelessness and associated health problems.
•Many rights of homeless
persons (such as the right of families to obtain emergency shelter in New
Jersey) and remedies to homelessness (such as the multi-billion affordable
housing program in New York City) have been won through judicial
interpretation of statutory and constitutional language associated with
welfare, including the Social Security Act. This language, which guarantees
certain benefits to all eligible persons, is likely to be repealed.
A growing number of
Americans are living in poverty and homelessness. Fundamental transformations
in public policy are required to address these phenomena; however, the sort of
welfare reform proposals approved by the House of Representatives and adopted
recently in States such as Massachusetts, Virginia, Wisconsin, and Maryland
are unlikely to diminish poverty - and are likely to increase homelessness.
The themes which consistently appear in these measures - time limits for the
receipt of assistance, the exclusion of children born to teenagers or to
parents already participating in the program, work requirements without
adequate training or child care, the denial of assistance to persons with
substance abuse-related disabilities - ignore the economic context in which
poverty has flourished, and punish those most in need of support.
With respect to the size of
the national economy ($7 trillion) and the Federal budget ($1.7 trillion),
welfare spending is very small. Aid to Families with Dependent Children
comprises 1% of the Federal budget and 3.4% of State budgets. In 1992, total
Federal spending for programs targeted to low-income persons equalled $208
billion, one-seventh of all Federal spending and one-third less than military
spending. Yet welfare reform appears to generate more interest than public
policies which have far greater economic impact.
This is the case because
welfare has become a metaphor representing the failures and dysfunctions of
many aspects of contemporary life. Rather than focusing on the growing
inequities of income distribution for most Americans and on structural
economic dislocations, welfare "reformers" divert our attention to the waste
and "dependence" which they associate with public assistance programs for a
portion of the poor. Reforming welfare allows policy makers to tinker with
relatively small public expenditures (with devastating effects upon the lives
of vulnerable members of our community), while failing to address fundamental
issues of mutual support and structural unemployment.
In the following pages we
briefly discuss the functions of welfare and of welfare "reform," describe the
public welfare programs which impact upon the health of homeless persons, and
analyze the changes in these programs which would result from likely
Congressional action. We also provide suggestions for effective advocacy at
the Federal level and at the State level - which will assume increasing
importance in the future, given the likelihood of block grants and the trend
toward "devolving" Federal authority to the States.
Welfare "reform" threatens
to further impoverish millions of vulnerable Americans, pushing many now on
the precipice into the abyss of homelessness. These reforms may also eliminate
the very tools which can rebuild shattered lives. In these circumstances, a
commitment to ending homelessness requires an understanding of the role of
welfare in our society, development of a clear vision of progressive
alternatives, and a marshalling of forces to implement that vision. It is to
these ends that this paper is dedicated.
Real People
Archie is a former
coal miner, police officer, and restaurant manager. His untreated depression
caused him to become unemployed and homeless fifteen years ago; living on the
streets of a Southern town, he became a notorious alcoholic. Five years ago he
was encountered by a Health Care for the Homeless outreach worker. His medical
problems - seizures, a hernia, anemia, a ruptured disk - were treated for the
first time (outside of his many episodic visits to local emergency rooms), and
after a protracted struggle, he was awarded SSI. Today Archie has his own
apartment and a Health Care for the Homeless representative payee who assures
that he takes his medication daily, that he has three meals a day, and that
his health problems are monitored. Should the changes in SSI, included in both
House and Senate versions of welfare reform, be implemented, Archie will lose
his SSI benefits and Medicaid. Homeless again, the costs of emergency room
treatment will far outweigh the savings in SSI payments.
Elsie suffered broken
bones, bruises, and black eyes at the hands of her husband for years. She was
afraid to leave him, because she didn't think that she could raise their two
children without his support. But when he pushed Paul, age 12, down the stairs
for "interfering," Elsie took Paul and Joanie, age 2, to another State where
they found shelter with a battered women's program. The social worker helped
Elsie apply for public assistance, but after 90 days, her benefits will be
terminated, because the State from which she fled requires that welfare
participants work after 90 days of benefits. Elsie has never worked outside
the home, and has no marketable skills. The shelter in which she is staying
also has a three month limit, and Elsie is faced with a choice between her
abusive husband and the streets.
Ramon is a 17 year
old father with full custody of his one year old son, Jorge. When he lost his
dishwashing job because of a downturn in the economy of his Midwestern city,
Roman applied for welfare. He was found ineligible, because he and Jorge's
mother were minors when Jorge was born. Ramon's family is unable to offer
support, and Jorge's mother has disappeared. Ramon and Jorge are temporarily
in an emergency shelter. Their pediatrician is concerned with Jorge's heart,
but Ramon and Jorge are also ineligible for Medicaid. The Health Care for the
Homeless program which has been providing medical services to Ramon and Jorge
is unable to afford the tests which Jorge needs because of budget-driven
cutbacks.
Chinua is a brilliant
linguist from Gambia who was diagnosed with schizophrenia while visiting
relatives in the United States. He wandered away from the city where his
relatives lived, and was found in a mission by a Health Care for the Homeless
outreach worker. Chinua had lost all of his identfying documents, and had not
received mental health services for months. Health Care for the Homeless
established a relationship with Chinua, securing shelter at a program
sensitive to the needs of a person with schizophrenia. Chinua began to receive
mental health services and SSI, and eventually gained his own apartment
through the Shelter Plus Care program. During a dinner of ground nut stew
which he prepared to mark the occasion of his newly-found independence, Chinua
regaled his guests - including his Health Care for the Homeless social worker
- with anecdotes in six languages. Unfortunately, the anti-immigrant
provisions of the House and Senate welfare reform measures would deny all
assistance to Chinua, likely forcing him back onto the streets.
